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є : Free and Reduced Price school meals application Forms
school year 2013-2014
Instructions For School Districts
This packet contains:
Required information that must be provided to households:
Letter to Households
Free and Reduced Price School Meals Application
Notice to Households of Approval/Denial of Benefits (notification is required if household is denied; notification is optional if household is approved)
Optional application-related materials that may be provided to households:
Sharing Information With Medicaid/Healthy Start, Healthy Families  Local Education Agencies (LEAS) may share student meal eligibility information with the Ohio Healthy Start, Healthy Families program. If the LEA chooses to do so, this form must be sent to households informing them of the right to decline disclosure of the information.
Sharing Information With Other Programs  If the LEA wishes to share student meal eligibility information with persons affiliated with programs of which parental consent is required, this form must be provided to households to obtain parental consent. See page 64 of the USDA Eligibility Manual for School Meals, 2011 edition to determine if parental consent is required.
Optional application-related materials that may be posted at the school:
Healthy Start, Healthy Families flyer informing households of the opportunity to apply for free health care coverage
The pages are designed to be printed on 8Н by 11 paper. Some pages may be printed front and back. You will need to identify the benefits that are offered in your school, such as afterschool snacks. [Bold bracketed fields] indicate where you need to insert school district specific information. For example, you must include your districts homeless liaisons phone number on the application. If you make additional changes, you must submit your application package to the Ohio Department of Education, Office for Child Nutrition for approval.
This prototype application package includes information regarding the exclusion of housing allowance for those in the Military Housing Privatization Initiative. If this is not pertinent to your school district, please modify as appropriate.
If you have questions, contact:
Ohio Department of Education
Office for Child Nutrition
25 South Front Street, Mail Stop 303
Columbus, Ohio 43215
(800) 808-6325 Telephone
(614) 752-7613 Facsimile
[Insert School District Letterhead]
Dear Parent/Guardian:
Children need healthy meals to learn. [Name of School] offers healthy meals every school day. Breakfast costs [$]; lunch costs [$]. Your children may qualify for free meals or for reduced price meals. Reduced price is [$] for breakfast and [$] for lunch.
1. Do I need to fill out an application for each child? No. Complete the application to apply for free or reduced price meals. Use one Free and Reduced Price School Meals Application for all students in your household. We cannot approve an application that is not complete, so be sure to fill out all required information. Return the completed application to: [name, address, phone number].
2. Who can get free meals? All children in households receiving benefits through the Supplemental Nutrition Assistance Program (SNAP) or Ohio Works First (OWF) benefits can get free meals regardless of your income. Also, your children can get free meals if your households gross income is within the free limits on the Federal Income Guidelines.
3. Can foster children get free meals? Yes, foster children that are under the legal responsibility of a foster care agency or court, are eligible for free meals. Any foster child in the household is eligible for free meals regardless of income.
4. Can homeless, runaway and migrant children get free meals? Yes, children who meet the definition of homeless, runaway, or migrant qualify for free meals. If you have not been told your children will get free meals, please call or email [school, homeless liaison or migrant coordinator] to see if they qualify.
5. Who can get reduced price meals? Your children can get low cost meals if your household income is within the reduced price limits on the Federal Eligibility Income Chart shown on this application.
6. Should I fill out an application if I received a letter this school year saying my children are approved for free meals? Please read the letter you got carefully and follow the instructions. Call the school at [phone number] if you have questions.
7. My Childs application was approved last year. Do I need to fill out another one? Yes. Your childs application is only good for that school year and for the first few days of this school year. You must send in a new application unless the school told you that your child is eligible for the new school year.
8. I get WIC. Can my child(ren) get free meals? Children in households participating in WIC may be eligible for free or reduced price meals. Please fill out an application.
9. Will the information I give be checked? Yes, we may ask you to send written proof.
10. If I dont qualify now, may I apply later? Yes. You may apply at any time during the school year. For example, children with a parent or guardian who becomes unemployed may become eligible for free and reduced price meals if the household income drops below the income limit.
11. What if I disagree with the schools decision about my application? You should talk to school officials. You also may ask for a hearing by calling or writing to: [name, address, phone number].
12. May I apply if someone in my household is not a U.S. citizen? Yes. You or your child(ren) do not have to be a U.S. citizen to qualify for free or reduced price meals.
13. Who should I include as members of my household? You must include all people living in your household, related or not (such as grandparents, other relatives, or friends) who share income and expenses. You must include yourself and all children who live with you. If you live with other people who are economically independent (for example, people who you do not support, who do not share income with you or your children, and who pay a pro-rated share of expenses), do not include them.
14. What if my income is not always the same? List the amount that you normally receive. For example, if you normally make $1000 each month, but you missed some work last month and only made $900, put down that you made $1000 per month. If you normally get overtime, include it, but do not include it if you only work overtime sometimes. If you have lost a job or had your hours or wages reduced, use your current income.
15. We are in the military, do we include our housing allowance as income? If you get an off-base housing allowance, it must be included as income. However, if your housing is part of the Military Housing Privatization Initiative, do not include your housing allowance as income.
16. My Spouse is deployed to a combat zone. Is her combat pay counted as income? No, if the combat pay is received in addition to her basic pay because of her deployment and it wasnt received before she was deployed, combat pay is not counted as income. Contact your school for more information.
17. Why am I being asked about giving my consent for an instructional fee waiver? Ohio public schools are required to waive the school instructional fees for children who quality for free meal benefits. School Food Service personnel must have parent consent to share student meal application if your child(ren) quality for a fee waiver. If you agree to allow your child(ren)s meal application to be shared with school officials to see if he/she/they qualifies for a fee waiver then check yes in part 5. If you do not wish for that information to be shared, then check no in part 5. Answering no to this question will mean your child will not be able to be considered for a fee waiver. Answering this question either way will not change whether your child(ren) will get free or reduced price meals.
18. My Family needs more help. Are there other programs we might apply for? To find out how to apply for Ohio SNAP or other assistance benefits, contact your local assistance office or call 877-852-0010.
If you have other questions or need help, call [phone number].
Si necesita ayuda, por favor llame al telщfono: [phone number].
Si vous voudriez daide, contactez nous au numero: [phone number].
Sincerely,
[signature]INSTRUCTIONS FOR APPLYING
A HOUSEHOLD MEMBER IS ANY CHILD OR ADULT LIVING WITH YOU
IF YOUR HOUSEHOLD RECEIVES BENEFITS FROM THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) OR OHIO WORKS FIRST (OWF), FOLLOW THESE INSTRUCTIONS:
Part 1: List all household members and the school name and school grade level for each child.
Part 2: List the 10-digit case number for any household member (including adults) receiving SNAP or OWF benefits.
Part 3: Skip this part.
Part 4: Skip this part.
Part 5: Answer yes or no and sign your name if you would like the application to be checked by school officials to determine if the child(ren) qualifies for a school instructional fee waiver.
Part 6: Sign the form. The last four digits of a Social Security Number are not necessary.
Part 7: Answer this question if you choose to.
IF NO ONE IN YOUR HOUSEHOLD GETS SNAP OR OWF BENEFITS AND IF ANY CHILD IN YOUR HOUSEHOLD IS HOMELESS, A MIGRANT OR RUNAWAY, FOLLOW THESE INSTRUCTIONS:
Part 1: List all household members and the school name and school grade level for each child.
Part 2: Skip this part.
Part 3: If any child you are applying for is homeless, migrant, or a runaway, check the appropriate box and call [your school, homeless liaison, migrant coordinator].
Part 4: Complete only if a child in your household isnt eligible under Part 3. See Instruction for All Other Households.
Part 5: Answer yes or no and sign your name if you would like the application to be checked by school officials to determine if the child(ren) qualifies for a school instructional fee waiver.
Part 6: Sign the form. The last four digits of a Social Security Number are not necessary if you didnt need to fill in part 4.
Part 7: Answer this question if you choose to.
IF YOU ARE APPLYING FOR A FOSTER CHILD, FOLLOW THESE INSTRUCTIONS:
If all children in the household are foster children:
Part 1: List all foster children and the school name and school grade level for each child. Check the box indicating the child is a foster child.
Part 2: Skip this part.
Part 3: Skip this part.
Part 4: Skip this part.
Part 5: Answer yes or no and sign your name if you would like the application to be checked by school officials to determine if the child(ren) qualifies for a school instructional fee waiver.
Part 6: Sign the form. The last four digits of a Social Security Number are not necessary.
Part 7: Answer this question if you choose to.
If some of the children in the household are foster children:
Part 1: List all household members and the school name and school grade level for each child. For any person, including children, with no income, you must check the No Income box. Check the box if the child is a foster child.
Part 2: If the household does not have a 10-digit SNAP or OWF case number, skip this part.
Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call [your school, homeless liaison, migrant coordinator]. If not, skip this part.
Part 4: Follow these instructions to report total household income from this month or last month.
Box 1Name: List all household members with income.
Box 2 Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. Check the box to tell us how often the person receives the incomeweekly, every other week, twice a month, or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount and check the box to tell us how often each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veterans benefits (VA benefits), and disability benefits. Under All Other Income, list Workers Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.
Part 5: Answer yes or no and sign your name if you would like the application to be checked by school officials to determine if the child(ren) qualifies for a school instructional fee waiver.
Part 6: Adult household member must sign the form and list the last four digits of their Social Security Number (or mark the box if s/he doesnt have one).
Part 7: Answer this question, if you choose.ALL OTHER HOUSEHOLDS, INCLUDING WIC HOUSEHOLDS, FOLLOW THESE INSTRUCTIONS:
Part 1: List all household members and the school name and school grade level for each child. For any person, including children, with no income, you must check the No Income Box.
Part 2: If the household does not have a 10-digit SNAP or OWF case number, skip this part.
Part 3: If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call [your school, homeless liaison, migrant coordinator]. If not, skip this part.
Part 4: Follow these instructions to report total household income from this month or last month.
Box 1Name: List all household members with income.
Box 2 Gross Income and How Often It Was Received: For each household member, list each type of income received for the month. Check the box to tell us how often the person receives the incomeweekly, every other week, twice a month, or monthly. For earnings, be sure to list the gross income, not the take-home pay. Gross income is the amount earned before taxes and other deductions. You should be able to find it on your pay stub or your boss can tell you. For other income, list the amount and check the box to tell us how often each person got for the month from welfare, child support, alimony, pensions, retirement, Social Security, Supplemental Security Income (SSI), Veterans benefits (VA benefits), and disability benefits. Under All Other Income, list Workers Compensation, unemployment or strike benefits, regular contributions from people who do not live in your household, and any other income. Do not include income from SNAP, FDPIR, WIC, Federal education benefits and foster payments received by the family from the placing agency. For ONLY the self-employed, under Earnings from Work, report income after expenses. This is for your business, farm, or rental property. If you are in the Military Privatized Housing Initiative or get combat pay, do not include these allowances as income.
Part 5: Answer yes or no and sign your name if you would like the application to be checked by school officials to determine if the child(ren) qualifies for a school instructional fee waiver.
Part 6: An adult household member must sign the form and list the last four digits of his or her Social Security Number (or mark the box if s/he doesnt have one).
Part 7: Answer this question if you choose to.
2013-2014 FREE AND REDUCED PRICE SCHOOL MEALS FAMILY APPLICATION
Part 1. ALL HOUSEHOLD MEMBERS Names of all household members (First, Middle Initial, Last)Name of school and school grade level for each child/or indicate NA if child is not in school.
School GradeCheck if a foster child (legal responsibility of welfare agency or court)
*If all children listed below are foster children, skip to Part 5 to sign this form. Check if
No Income FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Part 2. BENEFITS: If any member of your household receives Supplemental Nutrition Assistance Program (SNAP, formally Food Stamps) or Ohio Works First (OWF) benefits, provide the name and 10-digit case number for the person who receives benefits and skip to Part 5. If no one receives these benefits, skip to Part 3.
NAME: ____________________________________________ 10-DIGIT CASE NUMBER:___________________________________________Part 3. If any child you are applying for is homeless, migrant, or a runaway check the appropriate box and call [your school, homeless liaison, migrant coordinator at phone #] Homeless FORMCHECKBOX Migrant FORMCHECKBOX Runaway FORMCHECKBOX Part 4. TOTAL HOUSEHOLD GROSS INCOME (before deductions). List all income on the same line as the person who receives it. Check the
box for how often it is received. Record each income only once. 1. NAME(List all household members with income) 2. GROSS INCOME AND HOW OFTEN IT WAS RECEIVEDEarnings from work before deductionsWeeklyEvery 2 WeeksTwice MonthlyMonthlyWelfare, child support, alimonyWeeklyEvery 2 WeeksTwice MonthlyMonthlyPensions, retirement, Social Security, SSI, VA benefitsWeeklyEvery 2 WeeksTwice MonthlyMonthlyAll Other Income
(indicate frequency, such as weekly monthly quarterly annually(Example) Jane Smith$200 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $150 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $0 FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $50.00/quarterly__$ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $________/_______$ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $________/_______$ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $________/_______$ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $________/_______$ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX $________/_______Part 5. SCHOOL INSTRUCTIONAL FEE WAIVER ADULT CONSENT: Your child(ren) may qualify for a waiver of their school instructional fees. We must have your permission to share your meal application information with school officials if your child(ren) qualifies for a fee waiver. Answering this question will not change whether your children will get free or reduced price meals.
Please check a box: FORMCHECKBOX Yes I agree to have my meal application used to determine if my child(ren) qualify for a fee waiver.
FORMCHECKBOX No, I do not agree to have my meal application used to determine if my child(ren) qualify for a fee waiver.
Signature of Parent/Guardian for the Instructional Fee Waiver Question: _____________________________________ Date: ________________Part 6. SIGNATURE AND LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER (ADULT MUST SIGN)An adult household member must sign the application. If Part 4 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the I do not have a Social Security Number box. (See Privacy Act Statement on the back of this page.)
I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will get Federal funds based on the information I give. I understand that school officials may verify (check) the information. I understand that if I purposely give false information, my children may lose meal benefits, and I may be prosecuted.
Sign here: X________________________________________Print name:______________________________________Date: ______________
Address:_______________________________________________________________________Phone Number:_________________________
Last four digits of your Social Security Number: __ __ __ __ FORMCHECKBOX I do not have a Social Security NumberPart 7. Childrens ethnic and racial identities (optional)Choose one ethnicity:Choose one or more (regardless of ethnicity): FORMCHECKBOX Hispanic/Latino
FORMCHECKBOX Not Hispanic/Latino FORMCHECKBOX Asian FORMCHECKBOX American Indian or Alaska Native FORMCHECKBOX Black or African American
FORMCHECKBOX White FORMCHECKBOX Native Hawaiian or other Pacific Islander Dont fill out this part. This is for school use only.Annual Income Conversion: Weekly x 52, Every 2 Weeks x 26, Twice A Month x 24 Monthly x 12
Total Income: ____________ Per: FORMCHECKBOX Week, FORMCHECKBOX Every 2 Weeks, FORMCHECKBOX Twice A Month, FORMCHECKBOX Month, FORMCHECKBOX Year Household size: ________
Categorical Eligibility: ___ Date Withdrawn: ________ Eligibility: Free___ Reduced___ Denied___ Reason: ____________________
Determining/Approval Officials Signature: _____________________________________________________ Date: _____________________
Confirming Officials Signature: _____________________________________________________________ Date: _____________________
Follow-up Officials Signature: ______________________________________________________________ Date: _____________________
If selected for Verification, Date Verification Notice Sent:_________ Response Date: _________ 2nd Notice Sent: ________ Results Sent:_______
Verification Result: No Change _____ Free to Reduced Price _____ Free to Paid _____ Reduced Price to Free ____ Reduced Price to Paid ___
Income eligibility guidelinesHousehold sizeYearlyMonthlyWeekly121,2571,772409228,6942,392552336,1313,011695443,5683,631838551,0054,251981658,4424,8711,124765,8795,4901,267873,3166,1101,410Each additional person:7,437620144Your children may qualify for free or reduced-price meals if your household income falls at or below the limits on this chart.
Privacy Act Statement: This explains how we will use the information you give us.
The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Supplemental Nutrition Assistance Program (SNAP), Ohio Works First (OWF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number or other FDPIR identifier for your child or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the lunch and breakfast programs. We MAY share your eligibility information with education, health, and nutrition programs to help them evaluate, fund, or determine benefits for their programs, auditors for program reviews, and law enforcement officials to help them look into violations of program rules.
Non-discrimination Statement: This explains what to do if you believe you have been treated unfairly. In accordance with Federal Law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
NOTICE TO HOUSEHOLDS OF APPROVAL/DENIAL OF BENEFITS
For the 2013-2014 Program Year
Dear Parent/Guardian:
You applied for free or reduced-meals for the following child(ren):
______________________________ _____________________________
______________________________ _____________________________
______________________________ _____________________________
Your application was:
Approved for free meals.
Approved for reduced-price meals at $ __ for lunch, $ __ for breakfast, and
$ for snacks.
Denied for the following reason(s):
( ) Income over the allowable amount.
( ) Incomplete application because ___________________________________
( ) Other_________________________________________________________
If you do not agree with the decision, you may discuss it with the [School officials name] at [phone number].
If you wish to review the decision further, you have a right to a fair hearing. This can be done by calling or writing the following official:
Name (School Hearing Officials name)
Address
Phone
If you are not eligible now but have a decrease in household income, become unemployed, have an increase in household size or become eligible to receive Supplemental Nutrition Assistance Program (SNAP) or Ohio Works First (OWF) funds, fill out an application at that time.
Sincerely,
[signature]
_____________________________________ Name Title Date
SHARING INFORMATION WITH MEDICAID/Healthy Start, Healthy Families
Dear Parent/Guardian:
If your children get free or reduced price school meals, they may also be able to get free or low-cost health insurance through Medicaid or the State of Ohio Healthy Start, Healthy Families Program. Children with health insurance are more likely to get regular health care and are less likely to miss school because of sickness.
Because health insurance is so important to childrens well-being, the law allows us to tell Medicaid and Healthy Start, Healthy Families that your children are eligible for free or reduced price meals, unless you tell us not to. Medicaid and Healthy Start, Healthy Families only use the information to identify children who may be eligible for their programs. Program officials may contact you to offer to enroll your children. Filling out the Free and Reduced Price School Meals Application does not automatically enroll your children in health insurance.
If you do not want us to share your information with Medicaid or Healthy Start, Healthy Families, fill out the form below and send in (Sending in this form will not change whether your children get free or reduced price meals).
No! I DO NOT want information from my Free and Reduced Price School Meals Application shared with Medicaid or the Healthy Start, Healthy Families.
If you checked no, fill out the form below.
Child's Name: _______________________School:________________________
Child's Name: _______________________School:________________________
Child's Name: _______________________School:________________________
Child's Name: _______________________School:________________________
Signature of Parent/Guardian: ____________________________Date: _______
Printed Name:____________________ Address:_________________________
For more information, you may call [name] at [phone].
Return this form to: [address] by [date].SHARING INFORMATION WITH OTHER PROGRAMS
Dear Parent/Guardian:
To save you time and effort, the information you gave on your Free and Reduced Price School Meals Application may be shared with other programs for which your children may qualify. For the following programs, we must have your permission to share your information. Sending in this form will not change whether your children get free or reduced price meals.
No! I DO NOT want information from my Free and Reduced Price School Meals Application shared with any of these programs.
Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with [name of program specific to your school].
Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with [name of program specific to your school].
Yes! I DO want school officials to share information from my Free and Reduced Price School Meals Application with [name of program specific to your school].
If you checked yes to any or all of the boxes above, fill out the form below. Your information will be shared only with the programs you checked.
Childs Name: _____________________________ School: ___________________________
Childs Name: _____________________________ School: ___________________________
Childs Name: _____________________________ School: ___________________________
Childs Name: _____________________________ School: ___________________________
Signature of Parent/Guardian: __________________________________ Date: ___________
Printed Name: ______________________________________________________________
Address: ___________________________________________________________________
For more information, you may call [name] at [phone].Return this form to: [address] by [date].
EMBED AcroExch.Document.7
All households must be notified of their eligibility status. Households with children who are denied benefits must be given written notification of the denial. The notification must advise the household of the reason for the denial of benefits, the right to appeal, instruction on how to appeal, and a statement that the family may re-apply for free and reduced-price meal benefits at any time during the school year. Households with children who are approved for free or reduced price benefits may be notified in writing or orally.
PAGE \* MERGEFORMAT 3
National School Lunch Program/ Prototype Notification Letter
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